Inhalant Abuse: The Wolf in Sheep's Clothing
Publication: American Journal of Psychiatry Residents' Journal
Recent efforts aimed at analyzing new forms of substance abuse have led to identification of risks associated with electronic cigarettes (1) and synthetic cannabinoids (2). Additionally, guidelines pertaining to low-risk cannabis use have been established (3). However, less focus has been placed on the forgotten but commonplace use of readily available inhalants as a means of achieving a "high" and its relationship with comorbid mental disorders.
DSM-5 defines inhalant use disorder as a "problematic pattern of use of a hydrocarbon-based inhalant substance leading to clinically significant impairment or distress" (4). Estimates show that 11% of high school students use inhalants as a form of achieving a "high" (5). Current data also suggest that the lifetime prevalence of inhalant use among persons aged 18–25 years is 13.1% and 9.6% among those aged ≥26 (6). Furthermore, it is estimated that 70% of persons with inhalant use disorder meet criteria for at least one lifetime mood, anxiety, or personality disorder (7). Due to the lack of readily available diagnostic tools for detecting inhalant use, this commonplace practice of substance abuse goes largely undetected.
The case report below provides insight into inhalant use disorder in the context of comorbid depressive disorder. The discussion that follows provides definitions of various forms of inhalants, as well as description of the practice of inhalant abuse, including associated terminology ("street names"), popular culture cameos, and possible clinical adverse effects. To aid clinicians in identifying this behavior, initial diagnostic and management approaches, as well as guidelines for psychiatric comorbidity screening, are also discussed.
Case
"Steve" is a 20-year-old young man who was brought to the emergency department after being found in an altered mental state in his apartment during a safety check. The patient's urine drug screen was negative for cocaine, methadone, opiates, propoxyphene, benzodiazepines, barbiturates, and amphetamines. His ethanol screen was also negative, and his vital signs were within normal ranges, except for a blood pressure reading of 150 mmHg/100 mmHg. His initial medical workup did not reveal any abnormalities. A consult with the psychiatric service was ordered due to the patient's history of depression and clinical presentation.
During the psychiatric evaluation, the patient was tearful, withdrawn, and somewhat weak and unsteady. He reported "huffing" approximately nine cans of computer-keyboard dust cleaner daily over the past 3 months. He revealed that he lived alone, had lost his part-time job, and had been dismissed from his college courses, and he endorsed increasing isolation from his family. He was on probation following an arrest for attempting to steal computer-keyboard dust cleaner from a local hardware store. He denied active suicidal ideations. However, he did endorse an overall depressed mood, poor sleep, lack of appetite, and loss of interest in any activity that did not involve huffing, and he expressed guilt related to his continued use of inhalants and the negative consequences. He denied use of any other illicit substance.
The patient was admitted to the inpatient psychiatric unit for his safety and started on mirtazapine for his depression, sleep deprivation, and appetite loss. After a short hospitalization, he was enrolled in a dual-track treatment program aimed at treating both his mood and substance use disorders. At a 3-month follow-up, the patient reported not having abused inhalants during this period, and his mood symptoms were markedly improved.
Discussion
What Are Inhalants?
Inhalants include solvents, aerosol sprays, gases, and nitrites found in low-cost, legally sold, easily accessible household items. They typically contain hydrocarbons (aliphatic, aromatic, or halogenated), nitrous oxide (a gas), and nitrites (amyl, butyl, and isobutyl). DSM-5 distinguishes between these substances, with only hydrocarbon-based inhalants included under the inhalant use disorder diagnosis and nitrous oxide and nitrites assigned to the "other" diagnostic class (4). Terms commonly used by patients to describe inhalant abuse are presented in Table 1. In popular culture, inhalant abuse has been depicted in film. In the 2003 movie Thirteen, two protagonists are seen inhaling from a can of computer dust cleaner.
| Method of Abuse | Substances of Abuse | Laboratory/Diagnostic Tests |
|---|---|---|
| Huffing | Air blast | EKG |
| Sniffing | Whiteout | CBC and comprehensive metabolic panel |
| Bagging | Poppers | Urine drug screen |
| Dusting | Whippets | Urinalysis |
| Whipping | Highball | Rapid blood glucose |
| Nagging | Poppers | Continuous pulse oximetry |
| Glading | Bullet bolt | Arterial blood gas analysis |
Common Clinical Adverse Effects
Persons who engage in inhalant abuse rarely seek immediate medical attention. Due to their high lipid solubility, inhalants are rapidly absorbed across pulmonary membranes and into the bloodstream. Lipophilic hydrocarbons have high volatility, allowing them to readily cross the blood-brain barrier. They promote an initial feeling of euphoria, with an effect lasting between 15 and 45 minutes, leading to CNS depression. Symptoms include lethargy, somnolence, headache, ataxia, stupor, and possible seizures. The mechanism by which CNS depression occurs has not yet been fully elucidated; however, experts have postulated noncompetitive, reversible inhibition of the N-methyl-d-aspartate receptor; activation of the mesolimbic dopaminergic pathway; and increased GABA receptor activation (8).
Continued use and toxicity are associated with pulmonary, gastrointestinal, renal, neurologic, and cardiovascular adverse effects. Inhalant-associated "sudden sniffing death" refers to sudden cardiovascular collapse as a result of arrhythmia, occurring after the inhalation of halogenated hydrocarbons (containing chloride or fluoride), which are commonly found in degreasers and spot removers. Additionally, inhaling nitrous oxide from an inflated balloon or a whipped cream can ("whipping") can result in neurotoxicity manifesting as polyneuropathy, ataxia, and even psychosis (9).
Making the Diagnosis
Standard five- and seven-panel drug screens do not enable identification of inhalant abuse but should be used to rule out intoxication with other substances. An experimental study conducted in Sweden showed that inhaled 1,1,1,2-tetrafluoroethane, found in aerosol freezer sprays, resulted in a 0.002% postexposure urinary excretion of the inhaled amount, with an average half-life of only 58 minutes (10), suggesting that detection proves to be difficult even for just this one substance.
Where available, more extensive testing can include urinary trichloroethanol (for chlorinated hydrocarbons), urinary hippuric acid (for toluene exposure), or blood and exhaled toluene levels. However, these tests represent limitations to diagnostic strategy, since they are expensive and not readily available at most facilities. Characteristic odors can reveal recent inhalant abuse, including sweet solvent odor (halogenated hydrocarbons) and petroleum distillate odor (kerosene).
Differential diagnoses include intoxication with other substances (e.g., alcohol, cannabis, salicylates, opioids, benzodiazepines, barbiturates, nonbenzodiazepine sleep medications, carbon monoxide, and cyanide) that can cause CNS depression. Metabolic disturbances such as hypoglycemia, as well as misuse of medications such as metformin and isoniazid, should be ruled out.
Management and Further Screening
While inhalant intoxication usually resolves spontaneously, emergency treatment strategies should begin with advanced cardiac life support protocols, with the patient's airway, breathing, and circulation stabilized first. Basic medical workup, laboratory tests, and monitoring should follow, as summarized in Table 1. Differential diagnoses should be ruled out, including consideration of the use of antidotes such as naloxone and flumazenil. Consulting the local poison control center is prudent. Patients with mild to moderate respiratory distress typically benefit from the use of supplemental oxygen and beta-2 bronchodilators (albuterol), and seizures should be managed with intravenous benzodiazepines.
Once the patient is medically stable, a thorough psychiatric evaluation is required. This will enable clinicians to establish a diagnosis while screening for comorbid psychiatric illness, given that 70% of persons who abuse inhalants meet criteria for at least one lifetime mood (48%), anxiety (36%), or personality (45%) disorder (7).
Conclusions
Clinicians should maintain a high index of suspicion for inhalant abuse when encountering young, intoxicated patients with relatively normal medical and laboratory workup, negative urine drug screen, and negative alcohol screen. However, clinicians should understand the limitations associated with making the diagnosis of inhalant use disorder, including lack of readily available diagnostic laboratory tests. Screening for comorbid psychiatric illness should be prompt, along with treatment interventions. In summary, inhalant abuse remains a dangerous behavior among young adults and warrants the label of a "wolf in sheep's clothing" due to easy access to commonplace household items used as a form of substance abuse.
Key Points/Clinical Pearls
•
Inhalants are found in common, low-cost, legally sold household products and provide fast-acting euphoria, ultimately leading to CNS depression.
•
Lifetime prevalence of inhalant abuse is 13.1% among persons aged 18–25 and 9.6% among persons aged ≥26.
•
Seventy percent of persons who abuse inhalants have a lifetime prevalence of comorbid psychiatric disorders, including mood (48%), anxiety (36%), and personality (45%) disorders.
Footnote
The patient's name and other identifying details in the above case have been changed to protect the patient's privacy.
References
1.
US Department of Health and Human Services: E-Cigarette use among youth and young adults: a report of the Surgeon General–Executive Summary. Atlanta, Centers for Disease Control and Prevention, 2016. https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Exec_Summ_508.pdf
2.
Tait RJ, Caldicott D, Mountain D, et al.: A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clin Toxicol 2015; 54(1):1–13
3.
Fischer B, Russell C, Sabioni P, et al.: Lower-risk cannabis use guidelines: a comprehensive update of evidence and recommendations. Am J Public Health 2017; 107(8):1277
4.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC, American Psychiatric Publishing, 2013
5.
Eaton DK, Kann L, Kinchen S, et al.: Youth risk behavior surveillance–United States, 2011. MMWR Surveill 2012; 61(4):1
6.
National Institute on Drug Abuse: Monitoring the Future Study: Trends in Prevalence of Various Drugs. Bethesda, Md, National Institutes of Health, 2016. https://www.drugabuse.gov/trends-statistics/monitoring-future/monitoring-future-study-trends-in-prevalence-various-drugs
7.
Wu LT, Howard MO: Psychiatric disorders in inhalant users: results from The National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend 2007; 88(2–3):146–155
8.
Tormoehlen LM, Tekulve KJ, Nanagas KA: Hydrocarbon toxicity: a review. Clin Toxicol 2014; 52(5):479–489
9.
Iwata K, O'Keefe GB, Karanas A: Neurologic problems associated with chronic nitrous oxide abuse in a non-healthcare worker. Am J Med Sci 2001; 322(3):173–174
10.
Gunnare S, Ernstgard L, Sjogren B, et al.: Toxicokinetics of 1,1,1,2-tetrafluoroethane (HFC-134a) in male volunteers after experimental exposure. Toxicol Lett 2006; 167(1):54–65
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American Journal of Psychiatry Residents' Journal
Pages: 7 - 9
History
Published online: 1 February 2018
Published in print: February 01, 2018
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